Analysis Source of ignition Samples associated with the Grande-Anse incident were identified as explosives and laboratory analysis concluded that these materials would ignite if subjected to impact, friction, or heat. Because there was no source of friction or heat in the immediate vicinity, it is likely that the detonation occurred when the metal cage made contact with the explosive material on the tank top. Practices for the Safe Handling of Dangerous Goods Shipboard Practices The master and the chief officer were responsible in theory for making sure the entire operation was safe; however, in practice, they relied on the stevedore and the charterer's representative to load and unload the vessel. On many occasions, the NilsB, its crew, and the adjacent terminal were placed at risk, as the following examples demonstrate. Emergency procedures were not readily available, leaving crew members unprepared for situations such as a spill or fire in the cargo hold.29 The hold was separated into the 'tween deck and the lower hold using removable panels. This prevented the onboard sprinkler system from reaching all cargo. Moreover, by manipulating the heavy pieces of removable deck covers directly above the impact-sensitive cargo, the crew risked a possible explosion. The NilsB was not equipped with specialized equipment and cargo gear for handling dangerous goods. Instead, the stevedoring company supplied standard equipment and tools and the master performed no verification of the equipment to ensure that it was spark-proof or intrinsically safe. The vessel's safety management system documentation contains only a single sentence providing general instructions for the loading of dangerous goods. This gave the master little tangible guidance in ascertaining the best practices for cargo tools and equipment, stowage and securing of dangerous goods, cargo surveillance during the voyage, and cargo operations during loading and unloading. Stevedore Company Practices Unsafe conditions must be recognized before they can be reported by employees, who must then have a functional channel to do so. Individuals who are consistently exposed to a particular situation, however, come to see that situation as normal.30 Safety standards may therefore slowly deteriorate, with the result that those unsafe conditions, which would be seen as abnormal or unacceptable to an objective observer, are accepted as normal events and therefore go unreported. In this occurrence, the stevedores did not consider their handling practices for explosive cargo as dangerous. A 1997 book31 lists a number of "powerful disincentives" (both individual and organizational) that reduce the likelihood of incidents being reported. Effective safety management practices are critical to overcoming this. Organizations require proactive mechanisms to identify and mitigate hazards; training is required to recognize and manage risk, and there must be a system for continuous monitoring and feedback of experience from all personnel. In this occurrence, the stevedoring company had established safe working practices pursuant to its in-house safety management system. For the most part, however, these did not address the particular safety practices associated with this cargo and local employees did not recognize some unsafe conditions. For example: Cardboard boxes containing explosive material were found damaged upon arrival at the terminal or were sometimes damaged during unloading. Employees repaired some packaging with non-standard materials. Damaged outer packaging was replaced by cardboard boxes that were not designed for the spilled product or properly identified. New identification was hand-written on the replacement boxes. Inadequate housekeeping of the workplace made it difficult for employees to detect the area of spillage, the type of material spilled, and its source. The combination of practices during the unloading of the NilsB and the underestimation of the occurrence's seriousness therefore suggest that the safety management of both the terminal operator and the stevedoring company were insufficient to proactively identify and manage risks. Port Authority Practices The port authority has ultimate responsibility for the port's safety and security. The document "Assessment of Quantity Limitations- Distance for Explosives" (see AppendixE) provides general safety guidelines on the transit of explosive material across the Grande-Anse Terminal. The port is further guided by the Port Authorities Operations Regulations and its own emergency management plan. However, in order to safely conduct all port activities, including safety oversight, such guidelines need to be expanded into more detailed policies, procedures, and instructions. In addition, those involved in the port activities need to be appropriately trained in how best to comply. Because Port Saguenay lacks clear and specific policies, procedures, work instructions and specialized personnel to perform oversight, it- like other small ports- depends on various stakeholders for the safe transhipment of dangerous goods. This meant that Port Saguenay was unable to ensure adequate levels of safety. For example, there was insufficient oversight of: the number of boxes being damaged and the way they were repaired the speed at which forklifts were manoeuvring while in the presence of explosive cargo the type of the tools and equipment used to handle the explosive cargo An effective reporting and support system was also absent. There were no safety communications between the stevedoring company, the terminal operator, the vessel, the charterer's representative, and the port authority. Furthermore, no attempt was made to obtain the support of experts at TC Marine Safety or TC Dangerous Goods. Packaging and Stowage Packaging that is used to transport dangerous goods should be able to withstand the shocks of normal loading activity, and should bear markings proving that it was tested accordingly.32 The decision to choose one type of packaging over another is the shippers' and is mainly guided by the intended use, by receiver requirements, and by economics. However, the condition of some cardboard boxes indicates that the packaging was unable to withstand the rigours of shipping and handling en route33 and did not meet IMDG requirements. Furthermore, there are no standards for the pallets used for dangerous goods, even though palletizing of cargo is a common practice with the potential to affect operations. Inadequate pallets, for example pallets with sharp edges or missing or damaged flooring, can compromise the safe carriage of goods. In this occurrence, it resulted in cargo being dropped on the wharf and, as some pallets had missing flooring, the use of unsafe practices to remove them from the hold; i.e., to lift the pallets that were sitting on the tank top, the steel forklift prongs had to be slid under the pallets while scraping the steel deck. Transportation of Dangerous Goods Regulations Cargo Gear The TDG Regulations do not elaborate on cargo gear. It has been recognized by countries such as the United Kingdom, the United States, and Israel that there must be safety standards concerning equipment used to handle explosive cargo.34 This point has been further made in Annex2- Transport and Handling of ClassI Explosives (see AppendixF)- of the IMO MSC Circular675, Recommendations on the Safe Transport of Dangerous Cargoes and Related Activities in Port Areas. In this instance, the equipment used did not meet IMO safety standards. Steel cages which had not been insulated against shock or sparking were used. Other equipment was also not specific to working with dangerous goods- such as forklifts and steel tools. As noted earlier, these can pose a danger if they interact with spilled dangerous goods. Therefore, without guidance on cargo gear, stevedores as well as other dangerous goods handlers in Canada may be exposed to higher risks than are necessary. Training The vessel's master and the chief officer had received dangerous goods training and possessed the requisite knowledge and experience to be recognized as "responsible persons" in the IMO's Recommendations on the Safe Transport of Dangerous Cargoes and Related Activities in Port Areas. However, this training was not utilized in supervising the unloading of the dangerous goods from the vessel. The TDG Regulations highlight the value of training, specifically with regard to safe handling practices and the dangers associated with various dangerous goods. In this instance, the stevedores unloading the NilsB had received the requisite dangerous goods training, yet most did not appreciate the risk in handling the cargo- as illustrated by the way they handled it and by their reaction to the explosion. This may be indicative of ineffective training. To ensure the safe carriage of dangerous goods, those involved must be informed of the consequences of not adhering to safe working practices. In addition, there is no requirement for a formal evaluation of a person's training (initial and refreshers). The method of evaluation is currently left to the discretion of the employer and/or the training provider. Without a system to evaluate the effectiveness of training, it is likely that unsafe practices will continue. A more comprehensive system is used, for example, in Ohio and California, United States, where drivers who transport dangerous goods must hold a certificate from a competent authority or be trained at an authorized school. This is also true for signatories of the European Agreement Concerning the International Carriage of Dangerous Goods by Road (ADR). Ineffective training in the handling of dangerous goods followed by inadequate verification of the practical value of that training may put the lives of cargo handlers and others at risk. Oversight There are numerous parties involved in cargo handling, all of whom should possess sufficient knowledge, gained through appropriate training and experience, to perform their allotted tasks safely. The ability to recognize unsafe situations and to take effective action to thoroughly mitigate them is part of that knowledge base. In this occurrence, the parties who held at least part of that responsibility included the master and the chief officer, the charterer's representative, the stevedoring company, its management, supervisors and employees, and the port authority/terminal manager. TC Marine Safety and Transport Dangerous Goods directorates and NRCan, ERD also have roles, ranging from a degree of oversight by inspection through to availability as an expert resource. TC Marine Safety had adopted the practice of visiting every foreign ship handling explosives in the region but, in this instance, its role was limited to an initial inspection. Unlike other port warden services (such as inspections related to grain, metal concentrates, and on-deck timber) this was not required by regulation. In larger Canadian ports, it is common for one or more persons within the operations or harbour master's department to have both extensive knowledge of dangerous cargo operations and the authority to take action to prevent unsafe acts. IMO's MSC Circular 675 (subsequently replaced by Circular1216) recommends that a responsible person be designated when dangerous goods are handled in port. The Canadian regulations require that an officer or a person designated by the master be present while the goods are being handled. However, on the day of the accident, no such designated responsible person was present. Only when there is continuous competent oversight of cargo operations involving dangerous goods (especially Class1 explosives) can the risk to crews, vessels, stevedores, and other parties working in the area be reduced and the environment adequately protected. Emergency Response and Coordination Emergencies often involve numerous agencies and stakeholders whose actions are coordinated under an overall integrated response. Given the complex operations that occur at a port, such overall coordination is paramount. To best help those involved, decisions on how to best respond to an emergency should be made in advance and documented in a contingency plan. Although Port Saguenay had procedures in place for responding to both a cargo fire and a dangerous goods release at the terminal, these procedures were not followed. Moreover, the Emergency Response Assistance Plan (ERAP)35, which was required for the carriage of this particular shipment of dangerous goods, was not referenced. Therefore, by not following the Port Saguenay emergency management plan and the Emergency Response Assistance Plan (ERAP) that would have coordinated the actions of the port authority, the charterer's representative, the terminal operator, the stevedores, and the vessel's crew, an appropriate response was precluded. Reporting the Explosion It is essential that occurrences are reported in a timely fashion so as to allow appropriate response. In this occurrence, the information concerning the explosion was not communicated to appropriate stakeholders in a timely manner. The AWS officer was informed of the explosion by the OSH director of the stevedoring company approximately 85minutes after the explosion. Other than the TC Marine Safety Directorate and NRCan, ERD, no other stakeholder was advised on that day. Information was disseminated to all the stakeholders late on the afternoon of 24April2006 and some only received it the following day, 25April2006. This prevented a full response from being carried out; although it did not aggravate the situation, it created the potential for doing so. Timely occurrence reporting has been emphasized previously.36 In this occurrence, the delay by the AWS in transmitting the information prevented interested parties from taking timely action. A combination of inadequate packaging and poor loading and unloading practices resulted in explosive material being spilled and left on deck. Because there was no source of friction or heat in the immediate vicinity, it is likely that the detonation occurred when the metal cage made contact with the explosive material on the tank top. The lack of specific guidance in the vessel's safety management system documentation did not help the master ascertain the best practices for loading, stowage, transport, and unloading of dangerous goods. The safety management practices of the stevedoring company were insufficient to proactively identify and manage risks. The lack of detailed policies, safety procedures, work instructions, and specialized personnel prevented the port authority/terminal manager from ensuring adequate safety while the explosives were being handled. Furthermore, the limited guidelines that were in place were not followed.Findings as to Causes and Contributing Factors A combination of inadequate packaging and poor loading and unloading practices resulted in explosive material being spilled and left on deck. Because there was no source of friction or heat in the immediate vicinity, it is likely that the detonation occurred when the metal cage made contact with the explosive material on the tank top. The lack of specific guidance in the vessel's safety management system documentation did not help the master ascertain the best practices for loading, stowage, transport, and unloading of dangerous goods. The safety management practices of the stevedoring company were insufficient to proactively identify and manage risks. The lack of detailed policies, safety procedures, work instructions, and specialized personnel prevented the port authority/terminal manager from ensuring adequate safety while the explosives were being handled. Furthermore, the limited guidelines that were in place were not followed. Packaging that does not withstand the rigours of shipping and handling en route does not meet the requirements of the International Maritime Dangerous Goods Code (IMDG Code) and therefore poses a risk. The lack of an international standard for pallets used for dangerous goods increases the risks to their safe carriage. Without guidance on cargo gear, handlers of dangerous goods in Canada may face undue risks. Ineffective training in the handling of dangerous goods followed by inadequate verification of the practical value of that training may put the lives of cargo handlers and others at risk. Only when there is continuous competent oversight of cargo operations involving dangerous goods (and especially Class1 explosives) can risk to crews, vessels, stevedores, and other parties working in the area be reduced and the environment adequately protected. In the event of the vessel's sprinkler system being activated to suppress a fire, the 'tween deck covers would prevent water from reaching the cargo stowed in the lower hold, contrary to the vessel's Document of Compliance for the carriage of dangerous goods, thereby increasing the risk to the vessel and crew. The practice of handling 'tween deck covers directly over explosives stowed in the lower hold increases the risk of an explosion due to impact.Findings as to Risk Packaging that does not withstand the rigours of shipping and handling en route does not meet the requirements of the International Maritime Dangerous Goods Code (IMDG Code) and therefore poses a risk. The lack of an international standard for pallets used for dangerous goods increases the risks to their safe carriage. Without guidance on cargo gear, handlers of dangerous goods in Canada may face undue risks. Ineffective training in the handling of dangerous goods followed by inadequate verification of the practical value of that training may put the lives of cargo handlers and others at risk. Only when there is continuous competent oversight of cargo operations involving dangerous goods (and especially Class1 explosives) can risk to crews, vessels, stevedores, and other parties working in the area be reduced and the environment adequately protected. In the event of the vessel's sprinkler system being activated to suppress a fire, the 'tween deck covers would prevent water from reaching the cargo stowed in the lower hold, contrary to the vessel's Document of Compliance for the carriage of dangerous goods, thereby increasing the risk to the vessel and crew. The practice of handling 'tween deck covers directly over explosives stowed in the lower hold increases the risk of an explosion due to impact. The delay by the alert warning network system in transmitting the information prevented interested parties from taking timely action.Other Finding The delay by the alert warning network system in transmitting the information prevented interested parties from taking timely action. Safety Action Action Taken Following the field phase of the investigation, the TSB informed the Transport Canada (TC) Marine Safety Directorate of the safety issues identified. Recognizing the potential severity of the occurrence, TC organized a meeting on 04May2006. There were 29persons in attendance, representing the following: two vessel agencies, two carriers, the stevedoring company, Natural Resources Canada, provincial police (Sret du Qubec), TC Marine Safety and Dangerous Goods directorates, the port authority, and the TSB. All parties agreed to the following commitments: to have a specialist available at the port, to keep cargo holds clean, and to use proper safety tools and equipment. Safety Procedures at Quebec Port Terminals, Inc. Subsequent to the meeting held on 04May2006, an information and training session was provided to all employees at Quebec Port Terminals Inc. on 08May2006 concerning the following items: Cleanliness of work area and equipment: avoid contamination; Cargo-handling gear in good working order; Be vigilant: avoid complacency; An explosives expert on hand at all times; Visual inspection of work area, pallets, and packing to detect any anomalies; To be avoided: friction/ impact/ heat/ static electricity/creation of fine particles; Damaged packaging and/or leakage of products: Immediately stop the operations and consult with the explosives expert, contain the contaminated area, recover the product with appropriate equipment, dispose of the product in the designated area; Avoid handling the platform above the cargo within the ship; Evacuation alarm: ship's whistle=evacuation zone: gatehouse at the entrance to the terminal; No cellular phones or radios when handling detonators; No lighters or matches aboard the ship; No handling of cargo during electrical storms; Closing of propane bottle valves during work stoppages. Alert and Warning Systems Network After discussion with the TSB, the superintendent of Marine Communication and Traffic Services (MCTS), Quebec region, reminded alert and warning network system (AWS) staff of the need to adhere to emergency contact procedures. Marine Safety Information and Advisory Letters The TSB issued several Marine Safety Information Letters (MSIs) and a Marine Safety Advisory (MSA), as follows: MSI 04-06 (18 August 2006), apprising Hungarian officials of inadequate packing of explosive cargo; MSI 05-06 (18 August 2006), apprising German officials of spilled explosive materials and damaged and improperly sealed boxes and pallets; MSI 06-06 (18 August 2006), apprising Czech Republic officials of issues regarding packaging and the condition of pallets originating in that country; MSI 07-06 (07 September 2006), apprising Antiguan officials of inadequacies in the NilsB's fire suppression system; MSA 08-06 (12 July 2006), advising TC's Airport and Ports Program of various inadequate practises in the handling of explosive cargo; and MSI 09-06 (13 December 2006), apprising W. Bockstiegel Reederei GmbH Co. KG of insufficient guidance in the shipboard safety management system documentation regarding the carriage and handling of explosive cargo. In response to MSA 08-06, TC indicated several actions that have been taken. Two port state authorities involved (Germany and Sweden) were notified of the accident to ensure that vessels are loaded in accordance with the regulations. The Swedish authority has subsequently distributed a letter to concerned parties containing the Canadian notice for information, action, and future prevention. Also, new procedures were issued by Quebec Port Terminals Inc. in February2008. Amendments to the International Maritime Dangerous Goods Code (IMDG Code) TC submitted a proposal to the International Maritime Organization (IMO) to amend the text of the IMDG Code. The proposal concerning the handling of explosives addressed the suitability of cargo gear for handling explosives and the training of shore-based personnel. In December2008, the amendments were completed and the text of the IMDG Code now includes provisions regarding cargo handling gear and audits of the training required for shore-based personnel. The IMDG Code now states that loading and unloading procedures and equipment used should be of such a nature that sparks are not produced, in particular where the floors of the cargo compartment are not constructed of close-boarded wood.37 The IMDG Code now states that the competent authority, or its authorized body, may audit the company to verify the effectiveness of the system in place, in providing training of staff commensurate with their role and responsibilities in the transport chain.38 The provisions of the IMDG Code Amendment34 have been incorporated into Canadian Transportation of Dangerous Goods and Canada Shipping Act regulations by reference and will come into effect in January2010. NilsB Owners The registered owner has incorporated new procedures in its safety management manual and has issued new checklists in order to avoid similar occurrences.